We agree with Ms. Noble and Dr. Schoelles that it is unfortunate that there are not more high-quality studies of the abuse or addiction risk of prescribed opioids. We believe that we pointed out the concerning methodological limitations in our paper. We agree with Dr. DuPont and colleagues that, given our understanding of addictive processes and opioids, it is essential to evaluate pharmaceutical opioids for their effect on the brain's reward systems and their likelihood to induce syndromes that would result in abuse or addiction. Clinicians should know the risk potential of the medications that they prescribe. In 2005, an estimated 11.3 million individuals reported nonmedical use of prescription pain medications in the previous year (1). The percentage of these individuals who were receiving these medications for pain treatment is not known.

We agree that an important clinical question is whether long-term (for example, years) opioid treatment for chronic back pain, as can be seen in clinical practice, leads to addictive behaviors. However, we disagree that the best way to estimate this risk is through passive surveillance in short-term randomized clinical trials in which the outcome is neither primary nor secondary. Neither the prospective nor the experimental nature of a study can guarantee the validity of the data. Bias may be introduced because most of these trials were funded by pharmaceutical companies. Furthermore, we disagree that the reference group for patients with chronic back pain should be the "general population." The populations represented in the studies included in this portion of our review are clinical rather than experimental populations and therefore are more likely to approximate the patients with chronic back pain who are commonly encountered by clinicians. We believe the inclusion of studies conducted at 2 Veterans Affairs sites and those conducted in patients with psychiatric comorbid conditions improves rather than detracts from the generalizability of our findings.

Pain should be addressed and treated in all patients. However, previous substance abuse primes a patient for subsequent substance abuse (2–4), and caution should therefore be used in prescribing controlled medications for some patients. Clinicians writing prescriptions for controlled substances should be aware of a patient's previous or current misuse of alcohol and illicit drugs and should not dismiss this, as per Ms. Noble and Dr. Schoelles. We do not make a causal link between receipt of opioids and development of an addictive disorder, but rather we report our findings to highlight the need to consider the clinical history of the patient in pain when considering prescribing opioids.